Archive for the ‘Infectious Diseases’ Category

Influenza, or “the flu”, is a common infectious disease that ranges in severity, with some cases even resulting in death.

In South Korea, the number of the flu patients in 2016 was a record high, and more importantly, the flu season started 7 weeks earlier than usual (See Graph 1).

In an effort to curtail the effects of influenza, the Korean government introduced a Free Influenza Immunization Program for children ages 6-12 months in October 2016, and expanded the coverage up to 59 month-old children from September 2017.

In response to this, many people are now arguing for the expansion of the program to include school-aged children and teenagers (up to ages 18 years) as well.

Cost and Parental Concerns

The Korean government expressed its strong concerns at a policy forum held last month, and stated that covering 6,500,000 school-aged children every year is not practical due to a limited workforce and budget. However the socioeconomic cost of influenza is $25 billion USD, and it was also reported that vaccination in this age group could save the cost up to 7 billion USD.

Additionally any side effects from the vaccines are taken seriously by parents. However, the influenza vaccine safety has already been proven.

My position

Despite these concerns – which should be taken seriously – I, as a primary care physician and public health advocate, support the expansion of the program.

Regarding cost, it would be reasonable to cover younger children first and then expand to teens. Various parental concerns need to be fully addressed through community or school level meetings.

More importantly, I would like to introduce the notion of social justicehighlighting ‘herd immunity’. Children respond well to the vaccine. Even though they are just a fraction of the population, immunizing them could significantly diminish the chance of a widespread outbreak.

This effort is part of being a good citizen, and enhancing our social benefitby protecting more people.

500,000 doses are distributed annuallySanofi Pasteur is the sole manufacturer of the only FDA approved yellow fever vaccine YF-VAX in the US. 500,000 doses are distributed annually, one third to the US military are two thirds to the civilian clinics. In November, 2015 the vaccine supply was impacted when Sanofi Pasteur began the process of moving manufacturing of the vaccine to a new facility. A large number of vaccines were lost in a production problem therefore diminishing the supply. Although efforts were made by Sanofi Pasteur to extend the supply by rationing the doses left, the CDC was not notified of the issue and imminent depletion of supplies until spring of 2016.

Sanofi Pasteur does manufacture another yellow fever vaccine that is used widely around the world, Stamaril. Special approval as an investigational new drug (IND) was obtained from the FDA to be allow supply and administration of Stamaril in the US. Stamaril and the YF-VAX are comparable in efficacy and risk of side effects therefore seen as interchangeable. Usually, roughly 4,000 sites in the US administer YF-VAX, while only 250 have been chosen to be allowed to supply Stamaril.

Currently there is no policy in place to address vaccine production in a vaccine shortage situation, and this must be addressed in further regulation and policy.

This vaccine shortage is not the first nor unfortunately the last that will take place. With this in mind, a policy addressing vaccine production issues has to be put forth. This should include a notification process allowing enough time for enacting a contingency plan to boost supply through alternate production and possible rationing. A national policy that outlines the procedure of notifying the CDC of possible shortages along with penalties to the company if not followed is imperative to lessen the impact of a shortage or to prevent it altogether. A new component of the FDA vaccine approval process and annual inspection should be added as well requiring an action plan to produce vaccines in case of a failure of supply or of production transfer in cases of withdrawal of the company from the market. It is unacceptable that one manufacturer’s difficulty, mistake, or withdrawal from the market impacts the health of the entire nation when this could be prevented with planning and coordination.

After years of efforts, in March 2016 the Ministry of Health and Family Welfare added an indigenous rotavirus vaccine to the routine immunization schedule in four Indian States — Andhra Pradesh, Haryana, Himachal Pradesh and Odisha. For the first time, children in India have access to a life-saving rotavirus vaccine. This achievement was a critical milestone for the children of India. And in February 2017, the vaccine was launched in an additional five states.

The Government of India’s progress should be applauded, but national scale up is still lagging. The children living in the remaining states of India also deserve access to the rotavirus vaccine. Expanding rotavirus vaccine into the routine immunization schedule in all states will help protect millions of Indian children.

State parliamentarians, you must call on the Government of India to facilitate faster roll-out of the vaccine. It’s time to work with your state health teams to put the infrastructure and systems in place to introduce new vaccines in a safe and timely manner. The children in your states deserve better. As progress continues to lag, children continue to die from a preventable disease. The time is now, don’t wait.

However, progress has been slow. The Healthy Newborn Network tracks the status of chlorhexidine implementation worldwide. Many countries with the highest neonatal mortality rates (>30 deaths/1,000 live births) still remain in the “pilot/policy alignment”, “expressed interest”, and “no information” categories. Nepal started implementing its chlorhexidine program in 2011, and Madagascar in 2013. Nigeria and Afghanistan following suit only last year. Who is missing? The top three countries with the highest neonatal mortality: Angola, Pakistan, and Central African Republic.

At 50 cents per dose, and in a gel form that is straightforward to apply to the umbilical cord, it begs the question why chlorhexidine has not been implemented more widely. Certainly, there are challenges, such as “regulatory hurdles, supply issues, and misconceptions about guidelines for umbilical cord care”, but these are not insurmountable. The slow roll-out has consequences, given that chlorhexidine has the potential to save 422,000 lives over a five-year period.

It is time the world got its act together, and for Angola, as the worst-offending country, to demonstrate its leadership and tackle its mark of shame. We call on the Angolan Ministry of Health to work with international agencies such as WHO, USAID, and PATH to rapidly introduce and scale chlorhexidine disinfection across the country.

Roles of HPV vaccines

Human papillomavirus (HPV) causes more than 99 percent of cervical cancer. Persistent infection with certain types of HPV can lead to specific cancer such as cervix, anus, vagina, vulva, penis, mouth, or sinuses. In Japan, HPV infection leads to cervical cancer in about 10,000 women every year and 2,700 women die of cervical cancer every year. World Health Organization (WHO) recommends HPV vaccines in adolescents more than 9 years of age to prevent infection with types of HPV known to cause cervical cancer. It is clear that these vaccines significantly reduce the number of women who develop cervical pre-cancer. It is estimated that mortality rate of cervical cancer could be reduced by 70 to 80% if they are available diffusely on targeted population throughout the nation.

It was concerned that risk of HPV type 16/18 infection at the age of 20 would noticeably increased among girls born between 2000 and 2003 compared to other age groups (Fig A). This negative effect was estimated to be worse if resuming encouragement was extended until 2020. However, MHLW has not changed their policy yet in 2017 although the Japan Society of Obstetrics and Gynecology released statement of resumption of HPV vaccines encouragement.

Antimicrobial resistance (AMR) can arise from inappropriate use of antimicrobial medications (AMMs). In the United States, more than 80% of all AMMs are used in food animal production, including classes of medications that are on the WHO list of critically important AMMs. Prior to 2017, many AMMs for food animal production could be purchased and used without a prescription and for purposes such as “growth promotion,” rather than for treating a documented infection.

In 2012 and 2013, the FDA released Guidance for Industry, which sought to define judicious use of AMMs in food production, as well as to recommend that the animal pharmaceutical industry voluntarily change their labeling of critically important AMMs used in food production. In short, the FDA recommended that certain AMMs should no longer be used without veterinary oversight or solely for “growth promotion.” Using these medications against their labelled purposes would then constitute a violation of the Federal Food, Drug, and Cosmetic Act.

Despite pushback from industry groups such as the National Pork Producers Council and the National Turkey Federation, which argue that there is no firm science supporting the concept that AMMs in animal production result in AMR in humans, the FDA has shown some early successes of their new guidelines. According to reports published this year, the pharmaceutical industry voluntarily either changed all new drug applications to require veterinary oversight or withdrew the applications from consideration by January 2017. Credit: wellnesswarrior.org

However, there is more work to be done. Further guidance from the FDA should tighten controls on the use of AMMs in food production for disease prevention purposes. Currently, use of AMMs for disease prevention can includeprophylactic administration of subtherapeutic doses for prolonged periods, dosed imprecisely in feed or water, to entire herds or flocks. Additionally, organizations focused on veterinary medicine and animal care, such as the USDA, should be made part of the Transatlantic Task Force on Antimicrobial Resistance (TATFAR). Finally, improved animal husbandry in food production facilities (decreased crowding, improved sanitation) would lead to less infectious disease.

The HIV incidence rate in Uganda was the third highest in Sub-Saharan Africa in 2014. There are 1.5 million people living with HIV and a 7% HIV prevalence.

As is shown in the graph below, HIV prevalence decreased in the 1990s; however, since the introduction of anti-retroviral drugs, HIV incidence has been increasing. People have become more careless in their sexual practices as they now believe that if they contract HIV, they can simply take anti-retrovirals and live a long and prosperous life.

HIV is transmitted through body fluids to include blood, semen and breast milk. The main interventions have previously focused HIV transmitted through sexual contact and educating on condom use and condom distribution. However, the key drivers of HIV incidence are the following: 1.) high risk sexual behavior, to include early sexual debut, multiple sexual partners, and inconsistent condom use; 2.) low individual level risk perception; 3.) high STI prevalence; 4.) low utilization of antenatal care and breast feeding education; 5.) safe male circumcision services; 6.) sub-optimal scale up of ART; and 7.) gender inequalities including gender based violence. Further, the rate of HIV is higher in women (8.3%) than in men (6.1%).

A comprehensive policy that attempts to address the many issues that face women would greatly assist in lowering the incidence rate in Uganda. In an effort to stay aligned with President Museveni’s National HIV and AIDS Strategic Plan 2015/2016 – 2019/2020, President Museveni should also write and enforce an education policy to be implemented in the local hospitals around the country. (See link for more information on the National HIV and AIDS Strategic Plan 2015/2016 – 2019/2020 nsp2015.)

In February 2017, Virginia governor Terry McAuliffe signed legislation that legalizes syringe access programs in the state. Needle exchange programs provide anyone needing a clean needle with a place to exchange their used needle for a sterile needle at no cost. These programs can also offer HIV testing and counseling, alcohol swabs, and male and female condoms, among other resources that vary by organization.

According to the approved bill, these programs will only be implemented in regions meeting certain criteria created from information such as overdose rates, number of Hepatitis C cases, and morbidity data. Thanks to several federal and private funds, these programs will not take away from the state’s general funds.

CREDIT: SPENCER PLATT/GETTY IMAGES

There has been controversy regarding whether needle exchange programs are helpful or detrimental. In 2011, Archbishop Francis Chullikat spoke on behalf of the Catholic Church at the United Nations in opposition of harm-reduction programs. The Catholic Church believes that people dealing with drug addictions should be given tools and assistance to break free from their addiction as opposed to measures that allow them to “continue” in their cyclic, addictive behavior. On the other hand, the CDC and NIH both advocate that needle exchange programs play a role in preventing HIV transmission and other health problems among people who inject drugs.

A needle exchange program in Virginia is important for preventing an HIV outbreak, considering an outbreak like this has happened in Indiana and the number of HIV cases rose from a typical 5 cases a year to 200 cases in 2015. It is important for local government officials and residents to voice their support for needle exchange programs to ensure the continuity and growth of such programs. A needle exchange program can be the difference between a public health crisis and a public health victory.

The ColombianMinistry of Health and SocialProtection uses the 1,800m elevation mark when allocating money to low-altitude departments for dengue-related expenditures. This suggests that only half of Colombia’s 47 million residents are at risk for dengue. However, many people vacation at low altitudes where they risk becoming infected and bringing dengue back home. If low-altitude residents were better equipped to control mosquitos, then both residents and visitors would be better protected. Unfortunately, low-altitude residents shoulder a greater financial burden for mosquito prevention than the government. Rodriquez et al. (2016) reported that almost $85 million USD was the highest household burden (for prevention alone) between 2010 and 2012, while the highest government burden was only $35 million USD (for prevention, awareness campaigns, and control combined).

Vector-borne diseases make up some of the more common infections throughout the globe. The Centers for Disease Control and Prevention acknowledges mosquito-borne diseases, such as West Nile Virus, and tick-borne infections, such as Lyme disease, have a great impact on the United States. These vectors have found favor in climate change as they continuing to breed and pose a public health risk; carrying infectious agents that may be transmitted to humans through a bloodmeal.

In 2014, the State of Florida Department of Health published their mosquito borne diseases surveillance guidebook. Within these guidelines, specific mosquito-borne infections were addressed in regards to both detecting and preventing such diseases. Unfortunately, since this publication, the Zika virus outbreak developed and was found to have recently reached Miami-Dade county in Florida, where locally transmitted cases were confirmed. Given these locally acquired infections in Florida, the surveillance guidelines should be updated accordingly.

Number of Florida Acquired Zika Virus (gray line: per million)

While the Northeastern regions of the US are known to have their “tick season” in the Spring and Summer, Florida’s climate allows for a year-long risk of contracting a tick-borne diease. The standard lab diagnostic criteria for Lyme disease, the ELISA, detects antibodies against the bacterium, Borelia burgdorferi sensu stricto. However, it has continued to demonstrate poor sensitivity and overall reliability. Research from the University of North Florida has identified different strains of Borrelia that cause disease in humans. Thus, should one be infected with one of the different strains of Borrelia, one’s test is likely to be negative despite having actual disease. In recent years, Florida was found to have a 140% increase in Lyme disease cases since 1993 while reports of other tick-borne diseases have also increased. Hence, Florida researchers and public health professionals must partner together to revise and implement more up-to-date/accurate screening and awareness for vector-borne diseases.